medication abuse by rand l. kannenberg

MEDICATION ABUSE:MEDICATION ABUSE:

Over-the-Counter & Prescription Over-the-Counter & Prescription Drug Abuse & DependenceDrug Abuse & Dependence

Rand L. Kannenberg, M.A., LAC, CCM, CCS

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StatisticsStatistics Non-medical use of prescription medications ranks second only

behind marijuana in terms of illicit drug use in the U.S. Approximately 15 million Americans report using a prescription drug

for non-medical reasons at least once a year. An estimated 48 million people 12 and older (20% of the population)

have used prescription drugs for non-medical reasons at least once in their lifetimes.

Nearly 14% of adolescents and more than 17% of adults over 60 have abused prescription drugs.

10% of teenagers ages 12-17 have abused cough medicine to get high. The number of first time misusers of tranquilizers went up nearly 50%. ER visits related to abusing pain killers alone have increased almost

165%. 5.2 million persons are nonmedical users of prescription pain killers. Among 12th graders, 9.5% have used Vicodin® and 5.0% have used

OxyContin® without a prescription the past year. 55.7% of misusers of pain relievers report that they obtain them from

a friend or relative for free.

Marion Jones sentenced to 6 months for lying about Marion Jones sentenced to 6 months for lying about steroidssteroids

Her attorney quoted the bard in asking a judge to be merciful, but the former Olympic track gold medalist was sentenced Friday to six months in prison for lying to investigators about using performance-enhancing drugs and about her role in a check-fraud scam. Federal Judge Kenneth Karas imposed the maximum sentence suggested in Jones' plea deal, despite entreaties for a probation-only sentence from her and her lawyers.

http://sports.espn.go.com/espn/wire?id=3192894&section=oly

Adam Butler/Associated Press

Ledger's Death: Sleeping Pills, Anti-Anxiety Drugs Ledger's Death: Sleeping Pills, Anti-Anxiety Drugs Found at Scene Found at Scene

Actor Heath Ledger, 28, was found dead at a Manhattan residence Tuesday. Police told ABC News' Richard Esposito that prescription drugs including sleeping pills and two anti-anxiety medications likely played a part, and the death appeared to be accidental. http://abcnews.go.com/Nightline/Story?id=4173792&page=1

Djamilla Rosa Cochran/ WireImage

Teens and Prescription DrugsAdvertisement: “Drug Dealer” Transcript

2.3.08 TRT 00:30 (Scene opens with a drug dealer outside of a convenience store walking on a sidewalk and approaches

the camera.)Drug dealer: “What’s this? What’s this? Documentary? Man, right here, this is my business.”

(The drug dealer wanders up and down the sidewalk looking for potential customers and checks a pay phone for coins.)

Drug dealer: “Buying, selling, whatever, you know? Slow! Business is off, man. Sales are down. Seems like half my customers, they don’t even need me anymore, you know? I mean they’re getting

high for free…Out of their medicine cabinets.” (He throws up his arms and shakes his head in annoyance.)

Drug dealer: “How am I supposed to compete with that!? You got kids?” (Drug dealer points at the cameraman.)

Cameraman: “Yeah.”Drug dealer: “Well, next time something goes south with your kids don’t look at me, man. Ain’t my

problem. I didn’t do it. (Laughs.) I wish I did!”Narrator: “Teens don’t need a drug dealer to get high.”

Text: PARENTS. THE ANTI-DRUG. TheAntidrug.com 1-800-788-2800 Sponsored by Office of National Drug Control Policy/Partnership for a Drug-Free America®

Narrator: “Safeguard your prescriptions. Safeguard your teens.” Material provided by the Office of National Drug Control Policy

Teens and Prescription DrugsAdvertisement: “All My Pills” Transcript

2.3.08 TRT 00:30(Scene opens with a teenage boy sitting in a school cafeteria with a small tin box full of pills.)

(The teenage boy holds up a yellow pill.)TEENAGE BOY:" This yellow one is for my postpartum depression”

(The teenage boy smirks, puts the yellow pill on the table then pulls a white pill out of the tin and holds it up.) TEENAGE BOY: “This one, sciatica, whatever that is”

(The teenage boy puts the white pill on the table then pulls two blue pills out of the tin and holds them up.) TEENAGE BOY: “I got these after my hysterectomy, or my prostectomy or some ectomy”

(The teenage boy puts the blue pills on the table then pulls a red pill out of the tin and holds it up.) TEENAGE BOY: “And this guy is for the pain from my last hip replacement.”

(The teenage boy puts the red pill on the table then pulls an orange pill out of the tin and holds it up.) TEENAGE BOY: “And this orange one is…”

(The lunch bell rings and the teenage boy scoops his pills off the table and back into the tin) TEENAGE BOY: “Gotta go”

NARRATOR: “For teens, getting drugs can be as easy as opening your medicine cabinet.”(The screen goes black.)

Text: PARENTS. THE ANTI-DRUG. TheAntidrug.com 1-800-788-2800 Sponsored by Office of National Drug Control Policy/Partnership for a Drug-Free America®

Material provided by the Office of National Drug Control Policy

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ObjectivesObjectives List the most commonly abused prescription and over-the-counter

drugs

Describe effective prevention techniques for the different types of fraudulent and forged prescriptions

Describe the warning signs of health care workers and other professionals impaired by medications

Summarize the alternatives to controlled drugs to treat various medical and psychological problems

Identify and explain the differences between medication abuse and medication dependence

Describe the effects of medication intoxication and how to administer written scales for withdrawal

At the end of this seminar the participant will be able to:

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Agenda & OutlineAgenda & OutlinePart I

Social Implications: Community and Professionals

Part II

Clinical Strategies: Assessment and Treatment

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Schedule II.(A) The drug or other substance has a high potential for abusehigh potential for abuse. (B) The drug or other

substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. (C) Abuse of the drug or other substances may lead to severe severe

psychological or physical dependencepsychological or physical dependence..Schedule III.

(A) The drug or other substance has a potential for abuse less than the drugs or other substances in schedules I and II. (B) The drug or other substance has a currently accepted medical use in treatment in

the United States. (C) Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence.

Schedule IV.(A) The drug or other substance has a low potential for abuse relative to the drugs or other substances in

schedule III. (B) The drug or other substance has a currently accepted medical use in treatment in the United States. (C) Abuse of the drug or other substance may lead to limited physical dependence or

psychological dependence relative to the drugs or other substances in schedule III.Schedule V.

(A) The drug or other substance has a low potential for abuselow potential for abuse relative to the drugs or other substances in schedule IV. (B) The drug or other substance has a currently accepted medical use in

treatment in the United States. (C) Abuse of the drug or other substance may lead to limited limited physical dependence or psychological dependencephysical dependence or psychological dependence relative to the drugs or other

substances in schedule IV.

Schedules of controlled Schedules of controlled substancessubstances

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Opioids Opioids & morphine derivatives& morphine derivatives

hydrocodone(Schedules II, III, V)

Examples Hydrocodone with Acetaminophen, VicodinVicodin®, Vicoprofen®, Tussionex®, Lortab®, Tussend®,

Hycodan®, Anexsia®

Nicknamesvike, Watson-387

Route of Administrationswallowed

Desired Outcomespain relief, euphoria

Adverse Reactionsdrowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness,

coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death

OPI

“Opiates”“Narcotic Analgesics”

“Pain Killers”

Schedule of Substance

Schedule of Products

Oral (swallow)Intranasal (snort)

Injection (IV,IM,SUB Q)Inhalation (smoke)

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oxycodone(Schedule II) Examples

Roxicet®, Oxycodone with Acetaminophen, OxyContinOxyContin®, Endocet®, PercocetPercocet®, Percodan®, Tylox®, Roxicodone®

NicknamesOxy, O.C., killer

Route of Administrationswallowed, snorted, injected


Adverse Reactionsdrowsiness, nausea, constipation, confusion, sedation, respiratory arrest,

unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death

(Time Release Tablet)

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codeine(Schedules II, III, V)

ExamplesEmpirin® with Codeine, Fiorinal® with Codeine, Fioricet® with Codeine, Robitussin

A-C®, Acetaminophen, Guaifenesin or Promethazine (Phenergan®) with Codeine, TylenolTylenol® with Codeine with Codeine, morphine methyl ester, methyl morphine, Didrate® and Parzone® (dihydrocodeine), Papaverine® and Noscapine®

(Codeine and Isoquinoline Alkaloid), Cosanyl®, Cheracol®, Cerose®, Pediacof® Nicknames

Captain Cody, schoolboy

Route of Administrationinjected, swallowed




Barbiturate/Opioid

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morphine(Schedules II, III)

ExamplesDuramorph®, MS-ContinMS-Contin®, Roxanol®, Oramorph SR®, RMS®

NicknamesM, Miss Emma, monkey, white stuff

Route of Administrationinjected, swallowed, smoked




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hydro-morphone(Schedule II) Examples

DilaudidDilaudid®, dihydromorphinone

Nicknames Dust, Juice, Smack, D, Footballs

Route of Administrationswallowed, injected




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opium(Schedules II, III, V)

Exampleslaudanum, paregoric, papaver somniferum,

extracts/fluid/poppy/tincture/granulated/powdered/raw, Parepectolin®, Kapectolin PG®, Kaolin®, Pectin P.G.®

Nicknamesbig O, black stuff, block, gum, hop

Route of Administrationswallowed, smoked




Also used for diarrhea & cough.

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Opioids & morphine derivatives

other narcotics(Schedules II, III, IV)

ExamplesActiqActiq®, DuragesicDuragesic®, Sublimaze®, FentanylFentanyl®, Demerol®, methadone, Darvon®, Darvocet®,

Stadol®, Talwin®, Paregoric®, Buprenex®, propoxyphene, Propacet®, Innovar®, Mepergan®, pethidine

NicknamesApache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash

Route of Administrationswallowed, injected, smoked, snorted


Adverse Reactionsdrowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness, coma,

constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death

Lollipop Patch Not detected in immunoassays.

Lozenge on plasticstick between cheeksand gums in mouth.

Suck on it, twirl it.

Only for breakthroughcancer pain if 16 or older.

80 x stronger than morphine!

In its own class.

IV/IM

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Video #1Video #1“Opioids”“Opioids”

(3 minutes & 8 seconds)

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75% of chronic pain patients 75% of chronic pain patients

taking daily opioids have taking daily opioids have “sleep disordered breathing “sleep disordered breathing syndromes”syndromes”

obstructive sleep apnea (loud snoring usually related to obesity and other health problems)

central sleep apnea (breathing stops during sleep)

Versus estimates of only 2% to 5% observed in general population.

Suggests:1.) Opioids impact brain control of respirations and breath size; and

2.) Chronic pain patients taking daily opioids have “higher risk of morbidity and mortalityhigher risk of morbidity and mortality”

May require sleep study for continuous positive airway pressure (CPAP) deviceat bedtime with fan, tubes and mask.

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CNS depressantsCNS depressants

barbiturates(Schedules II, III, IV)

Examples(methohexital) Brevital®, (thiamyl) Surital®, (thiopental) Pentothal®, (amobarbital) Amyta®,

(pentobarbital) Nembutal®, (secobarbital) SeconalSeconal®, (amobarbital/secobarbital) Tuinal®, (butalbital) Fiorina®, (butabarbital) Butisol®, (talbutal) Lotusate®, (aprobarbital) Alurate®,

(phenobarbitalphenobarbital) Luminal®, (mephobarbital) Mebaral®Nicknames

barbs, reds, red birds, phennies, tooies, yellows, yellow jackets Route of Administration

injected, swallowed Desired Outcomes

reduced pain and anxiety; feeling of well-being; lowered inhibitions Adverse Reactions

slowed pulse and breathing, lowered blood pressure, poor concentration/fatigue, confusion, impaired coordination/memory/judgment, respiratory depression and arrest, death, sedation, drowsiness/depression, unusual excitement, fever, irritability, poor judgment, slurred speech,

dizziness, life-threatening withdrawal

BAR“Sedatives”

“Hypnotics”“Anxiolytics”

Used for mild sedation to surgical anesthesia.

Also used for pain (e.g., tension headaches) or as anticonvulsants.

Used less often for sleep/anxiety because more lethal if OD.

Used in euthanasia with most animals, as well as human executions and assisted suicides (usually with muscle relaxant and potassium).

Fiorecet® has Tylenol®/caffeine.

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CNS depressantsCNS depressants benzodiazepines(Schedule IV)

Examples(estazolam) ProSom®, (flurazepam) Dalmane®, (temazepam) RestorilRestoril®, (triazolam) HalcionHalcion®,

(midazolam) Versed®, (alprazolam) Xanax Xanax®, (chlordiazepoxide) LibriumLibrium®, (clorazepate) TranxeneTranxene®, (diazepam) Valium Valium®, (halazepam) Paxipam®, (lorazepam) AtivanAtivan®, (oxazepam) Serax®, (prazepam) Centrax®, (quazepam) Doral®, (clonazepam) KlonopinKlonopin®

Nicknamescandy, downers, sleeping pills, tranks

Route of Administration injected, swallowed

Desired Outcomesreduced pain and anxiety, feeling of well being, lowered inhibitions

Adverse Reactionsslowed pulse and breathing, lowered blood pressure, poor concentration/fatigue, confusion, impaired

coordination/memory/judgment, respiratory depression and arrest, death, sedation, drowsiness/dizziness,

life-threatening withdrawal

BZO or BZD SleepAntianxiety Alcohol withdrawal

NOT Ambien® or Lunesta®.

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CNS depressantsCNS depressants

flunitrazepamExample

Rohypnol Rohypnol (only manufactured and sold legally in Latin America and Europe) Nicknames

forget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies Route of Administration

injected, swallowed, snorted Desired Outcomes

reduced pain and anxiety; feeling of well-being; lowered inhibitions Adverse Reactions

slowed pulse and breathing, lowered blood pressure, poor concentration/fatigue, confusion, impaired coordination/memory/judgment, respiratory depression and arrest, death, visual and gastrointestinal disturbances, urinary retention, memory

loss for the time under the drug's effects, associated with sexual assaults

“Date Rape Drug”

Schedule IV, but illegal in the U.S. since 1996 because “Drug Induced Rape Prevention and Punishment Act.” Schedule III by WHO 1995.

GHB is Schedule I.

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Video #2Video #2“Benzos”“Benzos”

(2 minutes & 46 seconds)

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Dissociative anestheticsDissociative anesthetics KetamineKetamine(Schedule III)

ExamplesKetalar®, Ketalar SV®, Ketaset®, Vetalar®, Vetaket®

Nicknamescat Valium, K, Special K, vitamin K, jet, super acid, green

Route of Administrationinjected, snorted, smoked

Desired Outcomes"K-Hole," an "out of body," or "near-death" experience

Adverse Reactionsincreased heart rate and blood pressure, impaired motor function, numbness,

nausea/vomiting, delirium, depression, respiratory depression and arrest, amnesia, long-term memory and cognitive difficulties, used as a date-rape drug

Also known as a date rape drug.

Used primarily by veterinarians.

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StimulantsStimulantsamphetamines(Schedule II)

ExamplesAdderallAdderall®, Adderall XR®, DexedrineDexedrine®, Dextrostat®, BiphetamineBiphetamine®, Durophet®, Obetrol®

Nicknamesbennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers

Route of Administrationswallowed, snorted, injected, smoked

Desired Outcomesawake, alert, active, aware, appetite suppression, energy, euphoria, excitement, enthusiasm, enhancement of

the senses

Adverse Reactionshallucinations, delusions, picking at the skin, preoccupation with one's own thoughts, violent and erratic

behavior, increased heart rate, high blood pressure, increased metabolism, irregular heart beat, weight loss, heart failure, nervousness, insomnia, rapid breathing, tremors, loss of coordination; irritability,

anxiousness, restlessness, delirium, panic, impulsive behavior

AMP

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StimulantsStimulantscocaine(Schedule IIII)

ExamplesCocaine hydrochloride

Nicknamesblow, bump, C, candy, Charlie, coke, crackcrack, flake, rock, snow, toot

Route of Administrationswallowed, snorted, injected, smokedsmoked

Desired Outcomesawake, alert, active, aware, appetite suppression, energy, euphoria, excitement, enthusiasm,

enhancement of the senses

Adverse Reactionsdysphoric crash, death from respiratory failure, strokes, heart failure, increased heart rate,

high blood pressure, increased metabolism, irregular heart beat, weight loss, nervousness, insomnia, increased temperature, chest pain, nausea, abdominal pain,

seizures, headaches, malnutrition, panic attacks

COCCOC

Used in eye, ear, nose and throat surgeries.Used in eye, ear, nose and throat surgeries.

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methamphetamine(Schedule II)ExampleDesoxyn®

Nicknameschalk, crank, crystal, fire, glass, go fast, iceice, meth, speed

Route of Administrationswallowed, snorted, injected, smokedsmoked



Adverse Reactions inability to sleep, loss of appetite and weight, thin/gaunt, increased sensitivity to noise, agitation, restlessness, irritability,

aggressiveness, dizziness, confusion, impaired judgment, diarrhea and gastrointestinal complaints, difficulty breathing, headaches, tremors or seizures, nausea and vomiting, numbness, profuse sweating, chills, muscle cramping, pain and

tenderness, dehydration, low magnesium level, low potassium level, grossly dilated pupils, chest pain, increased or decreased heart rate, increased blood pressure, fever or hyperthermia, impaired speech and language, mania, psychosis

with hallucinations and delusions, anxiety, panic, fear of impending doom, depression and suicidal ideation, poor hygiene and body malodor, missing teeth, bleeding gums, infected gums, dental caries/decay/cavities, dry mouth,

removed enamel, teeth grinding, skin aging and damage, dryness, roughness, wrinkles, broken veins, dermatitis around the mouth, skin ulceration and infection, acne or sores, hair loss from repetitious pulling

MADextro-Levo-Methamphetamine, aka, D-Methamphetamine.

Vicks® Vapor Inhaler isLevo-Methamphetamine.

All these symptoms increased if made illegally in U.S., Mexico or Asia.

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StimulantsStimulantsmethylphenidate(Schedule II)

ExamplesRitalinRitalin®, Methylin®, ConcertaConcerta®

NicknamesJIF, MPH, R-ball, Skippy, the smart drug, vitamin R

Route of Administrationswallowed, snorted, injected



Adverse Reactionsincreased heart rate, high blood pressure, increased metabolism, irregular heart beat, weight

loss, heart failure, nervousness, insomnia

Cylert® (pemoline)discontinued byAbbott Laboratoriesin 2005 (liver studies).

Strattera®(atomexetine HCI)is a non stimulant.

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Anabolic steroidsAnabolic steroids(Schedule III)(Schedule III)

Examples(oxymetholone) Anadrol®, (oxandrolone) Oxandrin®, (methandrostenolone) Durabolin®, (stanozolol) Winstrol®,

(testosterone cypionate) Depo-TestosteroneDepo-Testosterone®, (boldenone undecylenate) Equipoise®, (nandrolone decanoate) Deca-Durabolin®, (nandrolone phenpropionate) Durabolin®

Nicknamesroids, juice, arnolds, gym candy, pumpers, cycling, stacking, pyramidingcycling, stacking, pyramiding, weight trainers

Route of Administrationinjected, swallowed, applied to skin

Desired Outcomesno intoxication effects excluding a general sense of feeling good about self while taking the medication(s),

increased size and strength of muscles, improved appearance, improved endurance, and decrease recovery time between workouts

Adverse Reactionselevated blood pressure and cholesterol levels, severe acne, premature balding, reduced sexual function,

testicular atrophy in males, prostate cancer in males, reduced sperm production in males, abnormal breast development in males (gynecomastia), masculinizing effects in females (more body hair including

development of beard, deeper voice, smaller breasts, fewer menstrual cycles), enlargement of the clitoris in females, may prematurely stop the lengthening of bones resulting in stunted growth in adolescents,

psychotic reactions, manic episodes, feelings of anger or hostility, aggression, violent behavior, blood clotting, liver cysts and cancer, kidney cancer

Taking multiple doses over time. Combining different types at once. Slowly escalating dose/reaching a peak/then tapering dose.

(Male sex hormone)

NOT Corticosteroids (e.g., Cortisone/Prednisone).

For allergy, breathing,pain, skin problems.

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Dextromethorphan Dextromethorphan ((DXMDXM))

ExamplesAlka-Seltzer Plus Cold & Cough Medicine®, Coricidin HBP Cough and ColdCoricidin HBP Cough and Cold®, Dayquil

LiquiCaps®, Dimetapp DM®, Robitussin® cough products, Sudafed® cough products, Triaminic® cough syrups, Tylenol Cold® products,Vicks 44 Cough Relief® products, Vicks NyQil LiquiCaps®

NicknamesCandy, CCC, Dex, DM, Drex, DXM, Red Devils, Robo, Robo-fizzing (if mixed with sodas or alcohol),

Rojo, Skittles, Syrup, Triple-C, Tussin, Vitamin D


Desired Outcomesauditory and visual hallucinations, dissociation, euphoria, heightened perceptual awareness, lethargy,

mania, perceptual distortion

Adverse Reactionsabdominal pain, blurred vision, brain damage, confusion, death, dehydration, disorientation, delusions,

dizziness, double vision, drowsiness, dry mouth, dry skin, dysphoria, fever, flaky skin, flushing of face, headache, hot flashes, impaired judgment, involuntary muscle movement, itchy skin, loss of

consciousness, loss of physical coordination, memory problems, nausea, numbness of fingers and toes, panic attacks, paranoia, poor mental performance, profuse sweating, rapid heart beat, rigid

motor tone, seizures, slurred speech, tremors, vomiting

More than 125 OTC cold,cough, allergy, sinus, andhay fever medications.

Anyone with debit/credit card can buyonline at all major U.S. pharmacies.

Kids/teens/adults may take entire box/bottle or more!

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Video #3Video #3“DXM”“DXM”

(1minute & 50 seconds)

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Weight loss pillsWeight loss pillsExamples

bitter orange, chitosan, chromium, conjugated linoleic acid (CLA), county mallow (heartleaf), ephedraephedra, green tea extractgreen tea extract, guar gum,

hoodiahoodia Nicknamessame as above


Desired Outcomes decrease appetite, block absorption of dietary fat, reduce fat, build muscle, increase calorie and fat metabolism, increase the feeling of

fullnessAdverse Reactions

constipation, bloating, diarrhea, indigestion, high blood pressure, heart rate irregularities, sleeplessness, seizures, heart attacks, strokes, death,

vomiting, flatulence

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Sleeping aidsSleeping aidsExamples

(doxylamine) Unisom Unisom® Sleeptabs™, (diphenhydramine) BenadrylBenadryl®, AllerMax®, Banophen®, Diphenhist®, Genahist®,

(dimenhydrinate) DramamineDramamine®, Calm-X®, Dimetabs®, Triptone®Nicknames

sleepers, downers, sleeping pillsRoute of Administration

swallowedDesired Outcomes

sleepAdverse Reactions

agitation, nervousness, excitability, not able to sleep, blurred vision, dizziness or fainting spells, irregular heartbeat, palpitations, chest pain, muscle or

facial twitches, pain or difficulty passing urine, seizures, drowsiness, dizziness, dry mouth, headache, loss of appetite, stomach upset, nausea, vomiting, diarrhea, constipation, confusion, restlessness, incoordination,

ringing in the ears, persistent and unusual rash or hives, wheezing, weakness, reddening of the skin, sensitivity to light

Also Tylenol® PM.

Motion sickness.

Antihistamines.

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Online or e-pharmacies Online or e-pharmacies fax broadcasting/blasting

“individuals in need of prescription drugs…”

“without a doctor’s recommendation…”

“by simply answering a set of questions…”

“save time and money because you don’t have to go to your doctor and the pharmacy…”

“the cheapest prescription drugs on the Internet…”

“Ultram,Soma,

Fioricet,Prozac,Buspar,

are the different drugs that are included in our weekly specials…”

“90 quantity for $51.99 and $84.99 for 180 quantity…”

All require a prescription. Only Fioricet® is controlled. Ultram® (tramadol) (opioid-like) and Soma (muscle relaxant) are abused.

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Minors ordering on the Minors ordering on the InternetInternet

Web sites to watch for:www.erowid.orgwww.dextroverse.orgwww.lycaeum.orgwww.myspace.com/dextromethorphan

and many thousands of others!

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““Pill mills”Pill mills”

(Internet pharmacies that provide controlled substances illegally)

DEA uses web crawler/data mining technology to identify, investigate and prosecute these so-called "pill mills"

They are addressed in the “White House's National Drug Control Strategy Focuses on Prescription Drug

Safety”

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Street useStreet use“pharming”

(taking handfuls of known or unknown tablets, capsules, powders and syrups in

one sitting)

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Identifying Drug-Seeking Identifying Drug-Seeking PatientsPatients

Escalating use(a pattern of overuse or escalation of use by the patient)

“Doctor shoppers”(patients who use at least two physicians, frequent

emergency departments, call or go in off hours on nights/weekends/holidays, and/or claim to be from “out of

town”)

“Scams”(applying enough pressure that a physician who initially says

“no” to a medication or a refill eventually changes the answer to a “yes” because it’s easier to write the

prescription than confronting the patient)

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Case Study 1Case Study 1

The client is a 33-year-old white and Native American Indian female referred by her private probation officer for a court ordered substance abuse evaluation. She is on probation for two years for felony possession of a controlled substance (Vicodin®). She is also on probation in another county for two years for felony prescription fraud (Vicodin®). She has lost custody of her children, is unemployed (only fired after the second conviction discussed below), is required to take non opioid pain medications only, is required to attend 12 step Narcotics Anonymous (NA) Meetings, has random and unannounced urine drug screens and attends weekly outpatient substance abuse therapy sessions.

She was first prescribed Vicodin® after having breast enhancement surgery. She took it as directed and never requested any refills. She was prescribed it again three years later for a hysterectomy and later that same year for rectal surgery. She “liked the feeling it gave [her]. It decreased [her] anxiety and made [her] feel calmer.” She and her husband moved in with his parents for five months while they were building a house. He left her and the children there alone for two weeks of business and hunting trips back to back. She had conflict with her in laws.

At the time she was working as an office manager for a neurologist and used his DEA number and called in the first false prescription to a Safeway® pharmacy. She took one tablet every four to five hours for three weeks, then one every two hours for three weeks, two every four hours for two to three weeks and finally two every two to three hours for three months. She called or faxed in approximately 15 prescriptions using four pharmacies (Target®, Safeway® and two others she won’t name because she has not yet been charged in those crimes). She initially ordered bottles with 30 tablets. She then increased to 60 tablets.

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Case Study 2Case Study 2The patient is a 43-year-old white female referred by her attending physician on the medical

unit at a local hospital. She is five days post operative with a lap assisted total abdominal colectomy and ileocectomy. A consultation was ordered with this clinician because the patient is increasingly confused and hallucinating. Her medical problems are secondary to a history of purging and laxative abuse (taking as many as 20-30 doses of laxatives a day since the age of 20 to lose weight or have a bowel movement). As a result of the laxative abuse she had slow transit constipation for years.

Three days after her surgery numerous prescription medications were located in her room and it was assumed that she was taking some or all of them on her own (Ativan®, Tylenol® with codeine, Vicodin®, Valium®, Ambien® and Klonopin®) in addition to what was being ordered by the hospitalist, the surgeon and administered by the nursing staff.

She receives the medications listed above from four physicians who do not know that other providers are treating the same patient for her lupus, fibromyalgia, osteoporosis, and arthritis. Her divorce is pending. Her 16-year-old recently ran away from a group home. Her 11-year-old lives with his father and her 6-year-old is currently staying with the patient’s sister. The patient was terminated from her job as a certified public school Kindergarten teacher for missing work. The employer had documentation that the patient had been diagnosed with Bipolar Disorder but she did not respond to corrective action plans. She reportedly took the following medications from various unknown prescribers: Seroquel®, Effexor®, Lamictal® and Adderall XL®.

At the time of the exam she was naked below the waist, had perplexed expression, her speech was nonsensical, she was hallucinating, and she was disoriented to person/place/date.She was diagnosed with Opioid and Sedative/Hypnotic/Anxiolytic Withdrawal Delirium (provisionally, ruling out Delirium related to medical conditions).

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““Opiophobia”Opiophobia” “Many health care providers

underprescribe painkillers because they overestimate the potential for patients to become addicted to medications such as morphine and codeine. Although these drugs carry a heightened risk of addiction, research has shown that providers' concerns that patients will become addicted to pain medication are largely unfounded. This fear of prescribing opioid pain medications is known as ‘opiophobia.’”

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Characteristics of Characteristics of overprescribing physiciansoverprescribing physicians

“The 4 Ds” from the AMA:1.) dated

(out of date regarding knowledge of pharmacology, differential diagnoses and management of various conditions);

2.) duped (vulnerable to manipulative patients);

3.) dishonest (willing to write prescriptions for controlled substances in exchange for

money or other favors); and

4.) disabled (impaired with a medical condition, psychiatric illness and/or chemical

dependency)

41

How to approach physicians How to approach physicians with concernswith concerns

Start with provider first. If not successful, then:

Report to in house impairment in house impairment programprogram if available. If not available,

then: Report to chief of appropriate chief of appropriate

clinical serviceclinical service. If at an office based practice instead, then:

Refer to external impaired programexternal impaired program. If not available, or if a complaint is

required first, then: Report to state licensing boardstate licensing board.

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Types of drug testingTypes of drug testing Pre-employment (part of application process) Random (“neutral selection” of employees or

all employees) For-Cause (same as “probable cause” and

“reasonable suspicion”) Periodic Announced (regularly scheduled

annual exams) Post-Accident (on-the-job vehicle or other

work related incident) Rehabilitation (part of treatment program

and/or before return to work) Safety-Sensitive (testing of employees with

safety-sensitive job duties)

NOT reliable unless unannounced, unscheduled and observed.

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Detection periodsDetection periods

amphetamines* 1-3 days (may not be detectable in urine until 4-6 hours after use)

barbiturates (short acting) 1 day

barbiturates (intermediate and long acting) 1-3 weeks

benzodiazepines 5-7 days

cocaine* 1-3 days (may not be detectable in urine until 2-6 hours after use)

opioids 1-3 days (may not be detectable in urine until 2-6 hours after use)

*prescription medications versus illicit forms of same or similar substances

(i.e., NOT street MA or street COC)

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Alternatives to controlled Alternatives to controlled drugs for anxietydrugs for anxiety

Most antidepressants (buspirone) Buspar® Anticonvulsants: (valproic acid) Depakote®

and (gabapentin) Neurontin® Selected (antihypertensives) beta blockers Atypical neuroleptics: (olanzapine)

Zyprexa®, (quetipine) Seroquel®, (risperidone) Risperdal®

(hydroxyzine) Vistaril® or Atarax®

(e.g.,Toprol® XL, Lopressor®).

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Alternatives to controlled Alternatives to controlled drugs for insomniadrugs for insomnia

Sedating antidepressants: trazodone (Desyrel®), doxepin (Sinequan®), amitriptyline (Elavil®), nefazodone (Serzone®), mirtazepine (Remeron®)

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Alternatives to controlled Alternatives to controlled drugs for ADHDdrugs for ADHD

(pemoline) Cylert® (bupropion) Wellbutrin® (desipramine) Norpramin® (venlafaxine) Effexor® (clonidine) Catapres® Selective serotonin reuptake inhibitors

(aka, “SSRI”) (e.g., Paxil®, Zoloft®, Prozac®, Lexapro®, etc.)

Strattera®(atomexetine HCI)is a non stimulant.

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Alternatives to controlled Alternatives to controlled drugs for paindrugs for pain

nonsteroidal anti-inflammatory drugs

acetaminophen antidepressants anticonvulsants steroids muscle relaxants

(i.e., aspirin, ibuprofen)

(corticosteroids)

(e.g., Soma®, Flexeril®)

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Suboxone® versus Suboxone® versus Methadone or LAAMMethadone or LAAM

(buprenorphine HCI/naloxone HCI dihydrate)

a “partial agonist”

has Naloxone in it to prevent people from crushing and injecting it which would cause instant withdrawal instead of intoxication

may cause respiratory depression and death if injected and/or if combined with benzodiazepines or other CNS depressants

preferred over Methadone for patients addicted to prescription opioids (instead of heroin)

sublingual tablets (that are slow to dissolve with bad taste)

negative side effects/adverse reactions commonly reported more than placebo: headache, pain, nausea and sweating

must be in opioid withdrawal before starting and must have empty stomach

blocks effects of all other opioids but Fentanyl®

only available from physicians who have completed Reckitt Benckiser Pharmaceutical, Inc. training. They are listed at: http://www.suboxone.com

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Guidelines for Writing Guidelines for Writing PrescriptionsPrescriptions

Building an alliance with the patient (informed consent means informing the patient of potential for physical

dependency with certain medications)

How to document in the medical record (how the action to use medication was chosen; that the patient was informed,

consented, and was competent to make the decision)

Duty to warn related to driving errors (patients must be informed of the risk of driving while taking certain

medications, combining alcohol with certain medications, and both discussions should be documented in the record)

Using medication conjointly with therapies (use medication only as part of an overall treatment plan with other forms of

therapy, including, but not limited to physical therapy, biofeedback, cognitive behavioral treatment, or even bibliotherapy)

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““Clinical Sobriety Checklist” Clinical Sobriety Checklist” (CSC)™ for medications(CSC)™ for medications

(Every blank in all three sections must be checked.)(AA)

_____awake_____alert

(Ox4)_____oriented to person_____oriented to place_____oriented to time_____oriented to events

(Walking/Talking)_____exhibits stable gait without ataxia (i.e., is coordinated

and balance is steady when standing or moving)_____conversive without slurred speech (i.e., communicates

and word pronunciation is clear when speaking)

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_____legal, illegal, prescription and over-the-counter substance(s) used;

_____amount/route of administration/frequency/duration of use;

_____when started using;

_____why using/used;

_____last use;

_____blood alcohol level and time;

_____breath test result and time;

_____urine drug screen results and time;

_____CIWA score and time;

_____COWS score and time;

_____CAGE score;

Prescription drug Prescription drug interview questionsinterview questions

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_____history of blackouts;

_____history of intoxication or withdrawal delirium;

_____history of intoxication or withdrawal seizures;

_____history of substance induced psychosis, mania, anxiety or depression;

_____longest time clean/sober,

_____history of addiction treatment;

_____history of addiction support;

_____history of addiction education;

_____history of substance related legal problems;

_____history of physical problems as a result of using; and

_____problems at home, work or school as a result of using.

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CAGE Questionnaire CAGE Questionnaire for Prescription Drugsfor Prescription Drugs

Medication dependence is likely if the patient gives 2 or more positive answers:

1. Have you ever felt you should CUT down your use of prescription drugs?

2. Have people ANNOYED you by criticizing your use of prescription drugs?

3. Have you ever felt bad or GUILTY about your use of prescription drugs?

4. Have you ever used prescription drugs as a way to

“get going” first thing in the morning (EYE- opener)?

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Drug addiction testDrug addiction test

Alcohol and Drug Addiction Test

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Substance dependence Substance dependence screeningscreening

(requires 3 or more of the following in 12 consecutive months):

Increased Tolerance;Withdrawal;

Increased Quantity or Duration;Persistent Desire but Inability to Decrease or

Discontinue Use;Increased Time to Obtain or Recover;

Social/Occupational/Recreational Impairment;Continued Use Despite Awareness of Related

Physical or Psychological Problems.

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Substance abuse screeningSubstance abuse screening(requires 1 or more of the following in 12

consecutive months):

Recurrent Use Resulting in Social/Occupational/Educational Problems;Recurrent Use in Physically Hazardous

Situations;Recurrent Substance-Related Legal Problems;Continued Use Despite Awareness of Related

Social or Interpersonal Problems.

No such thing as Polysubstance Abuse.

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Benzodiazepine withdrawal Benzodiazepine withdrawal symptom questionnairesymptom questionnaireFeeling unreal Very sensitive to noise Very sensitive to light Very sensitive to smell Very sensitive to touch Peculiar taste in mouth Pains in muscles Muscle twitching Shaking or trembling Pins and needles Dizziness

Feeling faint Feeling sick Feeling depressed Sore eyes Feeling that things are moving

when they are stillSeeing or hearing things that are

not really there (hallucinations)Unable to control your movements Loss of memory Loss of appetite

Each moderate score is given a rating of 1 and each severe score a rating of 2. The maximum score possible is 40, unless of course additional symptoms are included.

Note also whether the symptoms occurred when the tablets were reduced or stopped, or if the symptoms occurred when the tablets were the same. If the individual attains an overall score above 20 seek specialist medical help. If the individual endorses a number of severe symptoms seek specialist medical help. If the individual reports a

number of new symptoms seek specialist medical help.

May result in death!

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For each item, write in the number that best describes the patient’s signs or symptom. Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score.

Patient’s Name:___________________________ Date: ______________

Clinical Opiate Clinical Opiate Withdrawal Scale Withdrawal Scale

(COWS)(COWS)

.

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Resting Pulse Rate: (record beats per minute)

Measured after patient is sitting or lying for one minute.

0 pulse rate 80 or below

1 pulse rate 81-100 2 pulse rate 101-120

4 pulse rate greater than 120

Sweating:

Over past ½ hour not accounted for by room temperature or patient activity.

0 no report of chills or flushing1 subjective report of chills or flushing2 flushed or observable moistness on face3 beads of sweat on brow or face4 sweat streaming off face

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Restlessness:

Observation during assessment.

0 able to sit still1 reports difficulty sitting still, but is able to do so3 frequent shifting or extraneous movements of legs/arms5 Unable to sit still for more than a few seconds

Pupil Size:

0 pupils pinned or normal size for room light1 pupils possibly larger than normal for room light2 pupils moderately dilated5 pupils so dilated that only the rim of the iris is visible

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Bone or Joint Aches:

If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored.

0 not present1 mild diffuse discomfort2 patient reports severe diffuse aching of joints/ muscles4 patient is rubbing joints or muscles and is unable to sit still because of discomfort

Runny Nose or Tearing:

Not accounted for by cold symptoms or allergies.

0 not present1 nasal stuffiness or unusually moist eyes2 nose running or tearing4 nose constantly running or tears streaming down cheeks

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GI Upset:

Over last ½ hour.

0 no GI symptoms1 stomach cramps2 nausea or loose stool3 vomiting or diarrhea5 Multiple episodes of diarrhea or vomiting

Tremor:

Observation of outstretched hands.

0 No tremor1 tremor can be felt, but not observed2 slight tremor observable4 gross tremor or muscle twitching

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Yawning:

Observation during assessment.

0 no yawning1 yawning once or twice during assessment2 yawning three or more times during assessment4 yawning several times/minute

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Anxiety or Irritability:

0 none1 patient reports increasing irritability or anxiousness2 patient obviously irritable or anxious4 patient so irritable or anxious that participation in the assessment is difficult

Gooseflesh Skin:

0 skin is smooth3 piloerection of skin can be felt or hairs standing up on arms5 prominent piloerection

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Total scores

with observer’s initials

Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe;more than 36 = severe withdrawal

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Adult Inpatient Medical Adult Inpatient Medical DetoxificationDetoxification

Admission Criteria Checklist Admission Criteria ChecklistOpioids The patient is acutely intoxicated; OR The patient meets the criteria for another opioid The patient meets the criteria for another opioid

induced disorder listed in the current edition of the induced disorder listed in the current edition of the Diagnostic and Statistical ManualDiagnostic and Statistical Manual; OR

The patient is experiencing severe withdrawal (Clinical The patient is experiencing severe withdrawal (Clinical Opiate Withdrawal Scale is greater than 36)Opiate Withdrawal Scale is greater than 36); OR

There is evidence that severe withdrawal is imminent; AND The patient has been unsuccessful at a less intensive level of service (or such a

level is not currently an option because of safety); AND If the patient is voluntary, he or she has arranged for longer term treatment after

inpatient medical detoxification; AND The patient requires close monitoring for a coexisting or co-occurring physical,

emotional, behavioral, and/or cognitive condition; AND The patient does not require a medical admission; AND The patient does not require an inpatient psychiatric admission.

e.g., psychotic, manic, depressed, anxious, etc.

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Sedatives, Hypnotics, Anxiolytics The patient is acutely intoxicated; OR The patient meets the criteria for another sedative, hypnotic or anxiolytic

induced disorder listed in the current edition of the Diagnostic and Statistical Manual; OR

The patient is in severe withdrawal; OR There is evidence that severe withdrawal is imminent; AND The patient is not responsive to appropriate efforts to maintain the dose of

the substance(s) at therapeutic levels; AND There is evidence that the patient is in danger of seizures There is evidence that the patient is in danger of seizures

upon withdrawalupon withdrawal; AND The patient requires close monitoring for a coexisting or co-occurring

physical, emotional, behavioral, and/or cognitive condition; AND The patient does not require a medical admission; AND The patient does not require an inpatient psychiatric admission.


Admission Criteria Checklist Admission Criteria Checklist

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Admission Criteria Checklist Admission Criteria ChecklistStimulants The patient is acutely intoxicated; OR The patient meets the criteria for another stimulant The patient meets the criteria for another stimulant

induced disorder listed in the current edition of the induced disorder listed in the current edition of the Diagnostic and Statistical ManualDiagnostic and Statistical Manual; OR

The patient is in severe withdrawal; OR There is evidence that severe withdrawal is imminent; AND The patient requires close monitoring for a coexisting or co-

occurring physical, emotional, behavioral, and/or cognitive condition; AND

The patient does not require a medical admission; AND The patient does not require an inpatient psychiatric admission.

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TECHNIQUES USING TECHNIQUES USING (CLONIDINE) CATAPRES® (CLONIDINE) CATAPRES®

FOR OPIATESFOR OPIATESCATAPRES® SUBSTITUTION

FOR OPIOID WITHDRAWAL AT HOME1. Oral2. PatchThe clonidine patch comes in three strengths (#1, #2, #3) and delivers over one week the equivalent of a daily dose of oral clonidine. Go to http://www.txpsych.org/guidelineopiates.htm for dosing guidelines.3. Other useful medications for symptom control Lomotil® for diarrheaKaopectate® after a loose stoolPro-Banthine® or Bentyl® for abdominal crampsTylenol® for headacheFeldene® or Naprosyn® for back, joint, and bone painMylanta® for indigestionPhenergan® suppositories for nauseaAtarax® for nauseaLibrium® for anxietyBenadryl® or Restoril® for sleepSinequan® for insomnia, anxiety, dysphoria Go to http://www.txpsych.org/guidelineopiates.htm for dosing guidelines.

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TECHNIQUES USING TECHNIQUES USING (DIAZEPAM) VALIUM® OR (DIAZEPAM) VALIUM® OR

(CLONAZEPAM) KLONOPIN® (CLONAZEPAM) KLONOPIN® FOR ANXIOLYTICS, SEDATIVES, FOR ANXIOLYTICS, SEDATIVES,

HYPNOTICSHYPNOTICSVALIUM® OR KLONOPIN® SUBSTITUTION FOR

ANXIOLYTIC/SEDATIVE/HYPNOTIC WITHDRAWAL AT HOME

Sporadic or intermittent use of anxiolytic/sedative/hypnotics may not require a withdrawal regimen. These techniques are best suited for the chronic user (a patient who has been on a relatively stable dose continuously for six months or more). The longer-acting clonazepam can be used rather than diazepam (5 mg of diazepam = 1 mg of clonazepam).

Go to http://www.txpsych.org/guidelinesanxiolyticsedativehypnotic.htm for dosing guidelines.

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Rapid detoxificationRapid detoxification“Rapid opioid detoxification with opioid

antagonist [naltrexone, a derivative of naloxone] induction using general anesthesia has emerged as an expensive, potentially dangerous, unproven approach to treat opioid dependence…

These data do not support the use of general anesthesia for …rapid opioid antagonist induction.”

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The “4 Ds” of The “4 Ds” of quitting medicationsquitting medications

Deep breaths(to deal with the tension from no longer using medication: with mouth closed and shoulders relaxed,

inhale slowly and deeply through the nose, to the count of 7, pushing the stomach out; hold the breath to the count of 7; exhale slowing through pursed lips to the count of 7; repeat this cycle 3-5 times)

Drink water(to remove the medication from your system: drink 8-10 glasses of water a day for at least a week,

avoiding caffeinated beverages if possible)

Delay(to handle the temptation to use medication: wait out a craving or urge to use medication at least 1

minute, finding that it goes away whether or not the medication is used after no more than 5 minutes)

Do something else(to handle the psychological and/or physical desire to use medication: do other activities instead (review

your most important reasons for quitting, talk to yourself, exercise, doodle, work on a hobby or crossword puzzle, take a shower, etc.)

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Relapse PreventionRelapse Prevention

Exercise No. 1: Why Do I Want To Change?

Purpose. In this exercise, you will look at why you want to change. It is important to ask

yourself this question. If you only want to escape the problems that you are facing right now, this workbook will not help you. If you want to change your life, it will.

Instructions. Complete the following sentences.

The reason I decided to try to get sober and clean this time is . . . (Tell what happened that made you seek help, such as job, health, or legal problems.)

Unless I really want to give up alcohol and drugs, I will not get better. Things might get better for a short time, but this will not last. I want to change because . . .

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Goal setting

Guidelines: Goals must be achievable and measurable. There must also be a “who,” “what,” “where,” “why,”

“when/when/when” (start date, frequency, and duration), and “how” for each goal.

Talk about what you WILL DO, not what you won’t do. Short-term goals are those that can be accomplished while you are still

in treatment. Long term goals are those that can only be accomplished after

successfully completing treatment (because the skill hasn’t been learned yet or the opportunity to get involved in the behavior or activity won’t be available until after graduation).

One of substance abuse goals must include continued treatment and/or aftercare plans (in addition to regular attendance and participation in this individual or group therapy, which is assumed).

Your criminal behavior goals must include legal alternatives to the unlawful behavior that brought you into the system this time (if this applies).

The antisocial behavior goals must include legal alternatives to two (2) primary problem areas/patterns of negative thinking and acting related to your use of prescription or over the counter medication.

Sign/date goal sheet the first time used and initial/date each additional goal. Never write more than one (1) goal per session. Review (update/delete/add) after three (3) goals, and do discharge planning after six (6) goals (instead of writing new goals).

medication abuse by rand l. kannenberg

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